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PART VI.

 SPEcIAL TOPIcS

4 7 Suicide and Violence

Violent behaviors toward self or others are among the primary concerns in psychiatric practice. There exists a wide variety of historical and cultural views on suicide. Debates regarding suicide are usually focused on the meaning of suicide in religious, cultural, legal, and medical spheres. In most religious traditions, suicide is seen as a sign of disbelief or offense toward God. In some jurisdictions, suicide, even an incomplete attempt, is considered to be a crime. The consensual view of modern medicine is that suicide is a serious medical problem, and is almost always associated with mental illness. Medically assisted suicide (euthanasia) is yet another controversial issue. The “right to die” is often defended when facing severe physical suffer of conditions with hope of improvement beyond any possibility. No matter under what circumstance, suicidal behavior has significant impact on the victim’s immediate and extended family, friends, and the community. Suicidal behavior also represents a huge cost to the family and the society. In cases of suicide and violence, crisis intervention is necessary. Continuous psychiatric treatment should focus on improving impulse control, stress management, and hope restoration.

  Antipsychotics for acute agitation: oral concentrate vs. injections
▶▶ Oral concentrate ▷▷ Decreases the patient’s feeling of helplessness ▶▶ Injections ▷▷ Have more predictable absorption ▷▷ Eliminate the need for hepatic metabolism 

  Date Rape
▶▶ Also known as acquaintance rape ▶▶ The rapist is known to the victim, and often romantically involved ▶▶ Statistics ▷▷ Male students – 11% reported had committed date rape ▷▷ Female students – 16% reported were date raped ▶▶ Mental health issues ▷▷ Posttraumatic stress disorder (PTSD) symptoms ▷▷ Self-blaming for poor judgment or for provoking the rapist 

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relief of tension. such as anger. remove one restraint at a time at 5-minute intervals ▶▶ Documentation ▷▷ The reason for the restraints ▷▷ The course of treatment ▷▷ The patient’s response    Interview with psychotic patients ▶▶ Communication should be straightforward ▶▶ Clinical interventions should be explained ▶▶ Interview should be structured and modified according to the situation ▶▶ Interview should be ready to be terminated if necessary    Parasuicide ▶▶ Self-mutilation without wish to die ▶▶ Fifty times more common in psychiatric patients than in the general population ▶▶ Epidemiology ▷▷ Four percent in psychiatric-hospital patients ▷▷ Thirty percent of oral substances abusers ▷▷ Ten percent of intravenous substances abusers ▷▷ Gender – female to male = 3 to 1 ▷▷ Prevalence in psychiatric patients is at least 50 times higher than general population ▶▶ The cut ▷▷ Usually delicate.352 Part VI. not coarse ▷▷ Usually done in private ▶▶ The cutters ▷▷ Most in their 20s ▷▷ Most claim to experience no pain ▷▷ Often give reasons. and the wish to die . and sometimes improves depression    Emergency restraints ▶▶ Material – leather is the safest type ▶▶ Team – at least four staffs should be used ▶▶ Psychological support ▷▷ Explain to the patient the purpose of restraining ▷▷ A staff member should always be visible ▷▷ Reassurance should be continued through the process ▶▶ Safety ▷▷ At least two restraints should be used ▷▷ The patient’s head is raised slightly ▷▷ The restraints should be checked periodically ▷▷ When agitation improved. Special Topics   Depression and suicide ▶▶ Hopelessness predicts long-term suicidal risk ▶▶ High risk when recovering from depression ▶▶ A suicide attempt may fulfill the psychological need for punishment.

and obsession with the assault ▷▷  Group therapy  with other rape victims is often very helpful  . weaker. dependence. such as the arrest and conviction of the rapist. Suicide and Violence ▶▶ Mental health considerations ▷▷ Personality disorders ▷▷ Alcohol and substance abuse ▷▷ Introverted anger and tension ▷▷ Unconscious wish to punish self or an introjected object  353   Psychotherapy in emergency setting ▶▶ Goal ▷▷ To help patients’ self-esteem ▶▶ Techniques ▷▷ Listen – when don’t know what to say ▷▷ Respect – support wounded self-esteem ▷▷ Empathy – as in any psychotherapy ▷▷ Conceptualization – help clarify the history and feeling    Rape of men ▶▶ Legal concept ▷▷ Sodomy – unnatural intercourse.Chapter 47. including PTSD ▷▷ Some victims fear that they may become homosexual after being man-raped    Rape of women: principles of support and care for the victims ▶▶ Immediate support and opportunity to ventilate the fear and rage to ▷▷ Family members ▷▷ Physicians ▷▷ Law enforcement officials ▶▶ Assurance of knowing that she has socially acceptable means of recourse. can help a rape victim ▶▶ Individual therapy ▷▷ Usually starts with a supportive approach ▷▷ Restores the victim’s sense of adequacy ▷▷ Encourages the sense of control over her life ▷▷ Relieves feelings of helplessness. and passive ▷▷ Has similar traumatic experience as female victims of rape. sometimes refers to nonvaginal sexual activities ▶▶ Most common form is man-to-man anal intercourse ▶▶ Most often happens in prisons or other close institutions ▶▶ The perpetrator ▷▷ May be heterosexual. sodomy is often used as a legal term for male rape ▷▷ Rape – classically refers to nonconsensual penile penetration of the vagina. such as anal intercourse or oral sex. in some states the definition of rape has been changed to wider spectrum of nonconsensual sexual activity and not limited to man-to-woman act ▷▷ Sexual assault – a more general term. bisexual. or homosexual ▷▷ Seeks for discharge of aggression ▷▷ Has emotional gratitude of being a victor or conqueror ▶▶ The victim ▷▷ Is usually smaller.

5 million ▶▶ Lifetime chance of being victimized – 1/8    Rape: psychological trip of the victims ▶▶ Rape is often a life-threatening situation to the victims ▶▶ During the rape ▷▷ Shock.7–1.354 Part VI. fright. panic ▷▷ Desperate desire to stay alive ▶▶ After a rape ▷▷ Shame. humiliation ▷▷ Confusion ▷▷ Fear ▷▷ Rage ▷▷ Symptoms of PTSD ▷▷ Phobia about sexual interaction    Rape: statistics of rapists ▶▶ Age – 25 to 44 years ▶▶ Races – 51% white. from 15 months to 85 years ▶▶ Women of 16–24 years are at highest risk ▶▶ Most common location of rape – near or inside the victim’s home ▶▶ Approximately half of the victims are known to the rapists previously    Risk factors for homicide and aggressive behavior ▶▶ Upbringing ▷▷ Poor parental model ▷▷ Experience of violence in early childhood ▷▷ Poor education ▶▶ Life style ▷▷ No significant others available ▷▷ Unstable life style ▷▷ Isolated from social life ▶▶ Economic and legal situations ▷▷ Low socioeconomic status ▷▷ Unable to use resources of help ▷▷ Multiple arrest history ▶▶ Psychiatric condition ▷▷ Chronic drug and alcohol use . Special Topics   Rape: epidemiology ▶▶ Annual prevalence – 0. 47% black. 2% others ▶▶ Rapists and their victims tend to be from the same ethnic group ▶▶ Alcohol is involved in 34% rape cases ▶▶ Gang rape – 10% of cases    Rape: statistics of victims ▶▶ Age – wide variety.

and not to falsely lower clinical vigilance ▶▶ Provide no legal protection for the clinicians    Suicidal risk in ethnic groups ▶▶ In descending order ▷▷ Caucasians.Chapter 47. with highest risk in elderly white males ▷▷ Native Americans ▷▷ African-Americans ▷▷ Hispanic Americans ▷▷ Asian-Americans    Suicidal risks in patients with schizophrenia ▶▶ Young ▶▶ Male ▶▶ High premorbid functioning ▶▶ Akathisia ▶▶ Abrupt neuroleptic discontinuation ▶▶ Depression following the resolution of psychotic symptoms ▶▶ Commanding hallucinations  . Suicide and Violence ▷▷ History of psychiatric hospitalization ▷▷ History of violence or impulsive behavior ▷▷ Depression and anxiety ▶▶ Other ▷▷ Specific plan ▷▷ Available weapon  355   Suicidal ideas: assessment ▶▶ All patients must be assessed about suicidal thoughts ▶▶ Assessment includes ▷▷ Intent ▷▷ Plans ▷▷ Means ▷▷ Perceived consequences ▷▷ Personal history of suicide ▷▷ Family history of suicide ▶▶ Asking about suicide does NOT increase the risk of suicide    Suicidal prevention contracts ▶▶ Not recommended for ▷▷ Patients under influence ▷▷ New patients with whom no therapeutic alliance is established yet ▷▷ Emergency settings ▷▷ Psychotic or volatile patients ▶▶ Be cautious when using suicidal prevention contracts.

there were reports of induction of suicidal ideations in short term ▶▶ Lithium ▷▷ Maintenance treatment for bipolar and unipolar depression ▶▶ Antipsychotics ▷▷ Clozapine – proved to reduce suicidality ▷▷ Other second-generation antipsychotics may also reduce suicidal rate ▶▶ Electroconvulsive therapy – may reduce suicidal ideation for short term    Suicide: characteristics of completed and uncompleted ▶▶ Completed suicide ▷▷ Male ▷▷ Greater rate in Caucasian population ▷▷ Over 60 years of age ▷▷ Usually precipitated by a loss ▷▷ Lethal method – firearms. in the lumbar cerebrospinal fluid (CSF)  ▷▷ Changes in serotonin binding sites in suicide victims ▶▶ Genetic factors ▷▷ Twin studies and adoption studies provided evidence of genetic impact on suicidal behavior ▷▷ Polymorphism in the gene of tryptophan hydroxylase (TPH) – TPH is involved in the synthesis of serotonin. and an increased risk of suicide attempts    Suicide: biological therapeutics ▶▶ Antidepressants ▷▷ Treatment for depression may reduce suicidal ideations ▷▷ However.356 Part VI. were identified in human TPH gene. a serotonin metabolite. the presence of the L allele was associated with a reduced capacity to synthesize serotonin. hanging ▶▶ Uncompleted suicide ▷▷ Female ▷▷ Under age of 35 years ▷▷ Low lethality of method – overdose. wrist cut ▷▷ Ten percent will finally be successful  . Special Topics   Suicidality and mental illness ▶▶ Most people who commit suicide have a diagnosed mental disorder ▶▶ Any mental disorder – 95% ▶▶ Mood disorders – 80%. two alleles. U and L. where highest risk is in bipolar mixed state ▶▶ Alcohol dependence – 25% ▶▶ Schizophrenia – 10% ▶▶ Delirium and/or dementia – 5%    Suicide: biological factors ▶▶ Decreased serotonin in the central nervous system ▷▷  Low level of 5-hydroxyindoleacetic acid (5-HIAA).

or the individual shifting to a different socioeconomic level where the customary norm is no longer familiar to him or her    Suicide: epidemiology ▶▶ In the United States ▷▷ Annual mortality is 30. the eastern European countries. or 12.000. and Japan ▷▷ Suicide rates are more than 25 per 100. ▶▶ Three social categories of suicide – egoistic. Austria. and anomic ▶▶ Egoistic suicide ▷▷ Socially isolated individuals ▷▷ Lack of sense of social involvement and integration ▶▶ Altruistic suicide ▷▷ Individuals with excessive integration into a social group ▶▶ Anomic suicide ▷▷ Socially integrated individuals ▶▶ Distressed because of change of social stability. Italy. Ireland. Germany.000    Suicide: medical conditions that increase the risk ▶▶ Multiple sclerosis ▶▶ Huntington’s disease ▶▶ Seizure disorders ▶▶ Spinal cord injury ▶▶ Cancers ▶▶ Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) ▶▶ Chronic obstructive pulmonary disease ▶▶ Systemic lupus erythematosus ▶▶ Pain syndromes ▶▶ Peptic ulcer disease  . Egypt. Switzerland. and the Netherlands ▷▷ Lower than 10 per 100.5 per 100.Chapter 47.000 ▶▶ Countries with low suicide rate ▷▷ Spain. Suicide and Violence   Suicide: chronological risks ▶▶ Within 3 months of the onset of a major depressive episode ▶▶ Previous attempt ▶▶ The risk of a second attempt is highest within 3 months of the first attempt  357   Suicide: Durkheim’s theory Emile Durkheim (1858–1917) was a French sociologist.000 ▷▷ Increased rate in adolescent and elderly in recent years ▷▷ Ranked the 8th in the overall cause of death ▶▶ Countries with high suicide rate (suicide belt) ▷▷ Scandinavia. altruistic.

Special Topics   Suicide: National Strategy for Suicide Prevention ▶▶ Established in 2001 in National Institutes of Health (NIH) ▶▶ A framework for suicide prevention for the nation ▶▶ Primary goals ▷▷ Promote awareness of suicide as a public health problem ▷▷ Develop support and reduce stigma ▷▷ Develop suicide prevention programs ▷▷ Reduce access to lethal means ▷▷ Improve access to mental health services ▷▷ Improve surveillance system    Suicide: physicians ▶▶ Physicians have a higher suicide rate than general population ▶▶ Female physicians are at higher risk ▶▶ Physicians who commit suicide ▷▷ Have a mental disorder. or both ▷▷ More often by substance overdoses and less often by firearms than general population ▶▶ Physician specialties ▷▷ Psychiatrists are at greatest risk ▷▷ Ophthalmologists the second ▷▷ Anesthesiologists the third    Suicide: psychiatric evaluation ▶▶ Current psychiatric symptoms ▶▶ Past suicidal and self-injurious behavior ▶▶ Past treatment history.358 Part VI. particularly therapeutic relationships ▶▶ Family history ▶▶ Current psychosocial situation ▶▶ Psychosocial strengths and vulnerabilities    Suicide: psychosocial protective factors ▶▶ Children in the home ▶▶ Being pregnant ▶▶ Religiosity ▶▶ Positive social support ▶▶ Positive therapeutic relationship ▶▶ Reality test ability    Suicide: psychosocial risk factors ▶▶ Unemployment ▶▶ Living alone ▶▶ Lack of social support ▶▶ Domestic violence ▶▶ Recent deterioration in socioeconomic status ▶▶ Recent life stressors  . most often depressive disorder. substance dependence.

▷▷ Overwhelming affects (rage. emotionally charged form of aggression ▷▷ Probably a repressed desire of homicide ▶▶ Karl Menninger’s theory ▷▷ Suicide is an inverted desire of homicide ▷▷ Described self-directed Thanatos (death instinct. etc. to be killed. Suicide and Violence   Suicide: psychological theories ▶▶ Sigmund Freud’s theory ▷▷ Suicide is an introjected. sacrifice. and to die ▶▶ Contemporary theories ▷▷ Act on fantasies and wishes for what may happen after suicide – revenge. reunion with the dead. escape. rebirth.Chapter 47. guilt) ▷▷ Identification with a suicide victim ▷▷ Group dynamics – may be associated with mass suicides  359   Violent behavior: differential diagnosis ▶▶ Substance induced ▷▷ Alcohol idiosyncratic intoxication ▶▶ Personality disorder ▷▷ Antisocial ▷▷ Paranoid ▷▷ Obsessive compulsive ▶▶ Schizophrenia ▷▷ Catatonic ▷▷ Disorganized ▶▶ Infections ▶▶ Cerebral neoplasms ▶▶ Dissociative disorders ▶▶ Impulse control disorders ▶▶ Temporal lobe epilepsy. a Freudian concept) ▷▷ Described three components of hostility in suicide – the wishes to kill. punishment. bipolar disorder ▶▶ Uncontrollable violence secondary to interpersonal stress  .